How often should we screen for esophageal varices in patients with liver cirrhosis?

From the Guidelines

Patients with liver cirrhosis should undergo screening for esophageal varices at the time of cirrhosis diagnosis, with follow-up intervals determined by the initial findings and disease severity. For patients with compensated cirrhosis who have no varices on initial endoscopy, repeat screening should occur every 2-3 years, as suggested by 1. Those with small varices should be rescreened every 1-2 years, considering the risk of progression to large varices, as noted in 1. Patients with decompensated cirrhosis require more frequent surveillance, typically annually, due to the higher risk of variceal development and bleeding, as indicated by 1 and 1. If large varices are found or if the patient has experienced a variceal bleeding episode, they should receive appropriate treatment, such as non-selective beta-blockers like propranolol or nadolol, and/or endoscopic band ligation, rather than continued surveillance, as recommended by 1 and 1. The screening interval may be extended if there is evidence of liver disease improvement, such as sustained viral suppression in hepatitis B or sustained virologic response in hepatitis C, as suggested by 1 and 1. These recommendations prioritize the reduction of morbidity, mortality, and improvement of quality of life for patients with liver cirrhosis, based on the most recent and highest quality evidence available, particularly from 1, which provides the most up-to-date guidance on the management of variceal hemorrhage in cirrhotic patients.

Some key points to consider in the screening and management of esophageal varices in patients with liver cirrhosis include:

• The importance of initial screening at the time of cirrhosis diagnosis, as emphasized by 1 and 1.
• The role of non-selective beta-blockers in preventing variceal bleeding, as discussed in 1 and 1.
• The potential for endoscopic variceal ligation as an alternative prophylactic therapy, mentioned in 1.
• The need for more frequent surveillance in patients with decompensated cirrhosis, as highlighted by 1 and 1.
• The consideration of liver disease improvement in determining screening intervals, as suggested by 1 and 1.

Overall, the management of esophageal varices in patients with liver cirrhosis requires a comprehensive approach that takes into account the individual patient's risk factors, disease severity, and response to treatment, with the goal of reducing morbidity, mortality, and improving quality of life, as supported by the evidence from 1, 1, 1, 1, 1, and 1.

From the Research

Screening Frequency for Esophageal Varices

• The frequency of screening for esophageal varices in patients with liver cirrhosis is not explicitly stated in the provided studies, but the studies suggest that screening should be performed at the time of diagnosis to detect varices 2.
• A study published in 2002 found that the prevalence of esophageal varices in cirrhosis increases with the severity of liver disease, and that thrombocytopenia and splenomegaly are independent predictors of large esophageal varices 3.
• Another study published in 2020 found that low platelet count and ultrasonographic parameters such as spleen size, splenic vein size, portal vein size, and the presence of portosystemic collaterals are significantly associated with the presence of large esophageal varices 4.
• The American Association for the Study of Liver Diseases (AASLD) recommends that patients with cirrhosis undergo endoscopic screening for varices at the time of diagnosis, and that those with varices undergo surveillance endoscopy every 2-3 years if no varices are found, or more frequently if varices are present [2,5,6,3,4 are not directly related to AASLD, however they provide some insights].

Non-Invasive Markers for Esophageal Varices

• Several non-invasive markers have been studied as potential predictors of esophageal varices, including platelet count, spleen size, and ultrasonographic parameters 3, 4.
• A study published in 2006 found that the platelet count/spleen diameter ratio appears to be the best non-invasive predictor of esophageal varices developed so far, but that the available evidence is not yet sufficient to allow for the modification of the current policy of screening cirrhotic patients by endoscopy at the time of diagnosis to detect varices 2.
• Another study published in 2020 found that low platelet count and ultrasonographic parameters such as spleen size, splenic vein size, portal vein size, and the presence of portosystemic collaterals are significantly associated with the presence of large esophageal varices 4.

Cost-Effectiveness of Screening

• A study published in 2003 found that empiric beta-blocker therapy for the primary prophylaxis of variceal hemorrhage is a cost-effective measure, as the use of screening endoscopy to guide therapy adds significant cost with only marginal increase in effectiveness 6.
• The study found that the cost per initial variceal hemorrhage prevented was significantly higher for screening endoscopy followed by beta-blocker therapy or endoscopic band ligation compared to empiric beta-blocker therapy 6.